Parent / Guardian Information

Please provide information for a parent or guardian with legal custody to be contacted in case of illness or injury.

Guardian Name*

FirstLast

Relationship to Camper*

Email*

Preferred Phone Number*

Secondary Phone Number*

Home Address

(If different from above)

Street AddressAddress Line 2CityStateZIP Code

Second Parent / Guardian or other emergency contact

Emergency Contact Name*

FirstLast

Preferred Phone*

Secondary Phone*

Health History

Parents or guardians will be notified as soon as possible if there is an illness or serious injury, for minor injuries parents will be notified at time of pick-up.

Doctor's Name*

FirstLast

Doctor's Phone Number*

Does your child have any allergies, medical conditions, or dietary restrictions?*

Yes

No

If yes, please describe*

Is your child currently on any prescription or over-the-counter medication?*

Yes

No

If yes, please describe*

(dosage, time, side effects, etc.)

Have you completed the "Permission to Give Medication Forms"?*

Yes

No

I don't know

Are there any camp activities from which your child should be exempted for health reasons?*

Yes

No

If yes, please describe*

The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury. Check those which the camper CAN have.*

Acetaminophen (Tylenol)

Ibuprofen (Advil, Motrin)

Antihistamine/allergy medicine

Guaifenesin cough syrup (Robitussin)

Sore throat spray Generic cough drops

Lice shampoo or cream (Nix or Elimite)

Antibiotic cream Calamine lotion Aloe

Bismuth subsalicylate for diarrhea (Pepto-Bismol)

Diphenhydramine antihistamine/allergy medicine (Benadryl)

General Health History

Please check YES or NO for each statement. Explain YES answers below.

Has/does the camper:*

Yes

No

1. Ever been hospitalized?

2. Ever had surgery?

3. Have recurrent/chronic illnesses?

4. Had a recent infectious disease?

5. Had a recent injury?

6. Had asthma/wheezing/shortness of breath?

7. Have diabetes?

8. Had seizures?

9. Had headaches?

10. Wear glasses, contacts, or protective eyewear?

11. Had fainting or dizziness?

12. Passed out/had chest pain during exercise?

13. Had mononucleosis ("mono") during the past 12 months?

14. If female, have problems with periods/menstruation?

15. Ever had back/joint problems?

16. Have a history of bedwetting?

17. Have problems with diarrhea/constipation?

18. Have any skin problems?

Please explain “Yes” answers in the space below, noting the number of the questions.

The camp may contact you for additional information.

What Have We Forgotten to Ask?

Please provide in the space below any additional information about the camper’s health that you think important or that may affect the camper’s ability to fully participate in the camp program. Attach additional information if needed.

File

Parent/Guardian Authorization for Health Care

This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the Health or Program Director to administer medication as needed. I understand the information on this form will be shared on a "need to know" basis with camp staff. In addition, the camp has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status. In the event I cannot be reached in an emergency, I hereby give permission to the Boys & Girls Club to provide treatment, for the person named above. This completed form may be photocopied for trips out of camp. The BGCM and its employees are held harmless and indemnified from any action taken in good faith.

Refusal to Treat

It is respectfully requested that my child be exempted upon religious grounds from the all immunization requirements required for attendance at Summer by the Sea Day Camp. To the best of my knowledge and belief, s/he is and has been in normal good health and is free from all communicable or contagious diseases.

Should my child manifest any condition where there appears to be reasonable grounds for suspecting the presence of a communicable or contagious diseases, I agree that a physical examination may be performed by a health care provider of my choice. Also, I agree that if any such disease is found, my child will comply with the regular sick camper policies.

It is further understood that, should an emergency arise, I will be notified immediately. However, in the event that we cannot be located immediately, the authorities of the camp may take such temporary measures as they deem necessary.

I release and forever discharge the camp and each and every one of its officers, directors, partners, shareholders, employees, agents, insurers, affiliates, successors in interest, attorneys, or any other person or persons associated with any or all of them or any variation in the name of any or all of them who might be liable (the “Released Parties”) from all causes of action, suits, claims, demands, or any other damages or costs associated with actions taken by the Released Parties relative to the health, sickness, and treatment of my child.

I further understand and acknowledge that I make this release in full accord and satisfaction of and in compromise of any current or future disputed or alleged claims or causes of action relative to the health, sickness, and treatment of my child against the Released Parties.

I represent and acknowledge that I have read and understand this agreement and release and warrant that all statements made herein are true to the best of my knowledge. I further warrant and acknowledge that I am of legal age, legally competent to execute this agreement and release, and accept full responsibility there for.

Release of Campers

Parents have entrusted us with their most precious possession – their children. We must do all we can to provide them the best care while they are our responsibility. Therefore, the following guidelines are intended to avoid any problems:

All campers are to be released only to an authorized person. Parents/guardians must complete and sign a form (see below) authorizing release of the camper to anyone other than the custodial parent or legal guardian. Photo Identification will be required for release of campers to authorized persons.

Authorized persons are to be directed to the camp director to sign their camper out.

If custodial parent requests that a camper not be signed out to a noncustodial parent, such a request must have a copy of the legal order.

When a last-minute change occurs in who will be picking up a camper, the new instructions are to be verified with the camp director from an authorized person.

No camper may leave camp at any time without prior authorization from the custodial parent and the camp director.

No-Shows/Absentees

To be sure that camper have not unexpectedly disappeared, the following procedures will be implemented if a camper does not appear:
Day Camp – Day campers are to be checked in each day. Parents are asked to notify the camp if a child is ill or will not be attending as expected. Camp personnel will attempt to call parents/guardians and/or emergency contacts if campers are not signed in as expected.

Camper's Name*

FirstLast

List

Click (+) to add multiple authorized persons. If this section is left blank, child can only be released to parent or guardian.

Permission for General Activities & Field Trips

I give permission for my child, to participate in all camp activities, including gym, swimming, and SMART Moves Programs; as well as any age appropriate group clubs, i.e. Passport to Manhood, RSVP Reading Buddies, and Runners Club.

It is understood that my child is expected to behave in a safe and respectful manner while on trips, this includes respecting the staff, bus, and each other; failure to do so may result in termination of trip privileges. My child will not be allowed to participate in this activity until a parent or guardian signs this form. Please return this permission form, as soon as possible. If the permission form is not on file your child will not be permitted to participate. Boys & Girls Club will no longer accept verbal permission on the day of the trip;